Anxiety Disorders Flashcards
Generalized Anxiety Disorder
general
Genetic tendency, high correlation with traumatic event and depression; usu onset before 65 yoa
Constant worry that something bad is going to happen which impairs life
Often have co-occurring psych dx, especially mood disorder
Chronic, low-level, insidious anxiety- worry about most things most of the time
Often develop physical symptoms and panic attacks
“constant state of worry” > 6 months, > 3 somatic complaints
Change in sleep, weight, irritability, concentration
Headache, stomachache, palpitations, sweating, chest pain, N/D, tingling- “anxiety hides in skin and gut”
Work up: must rule out underlying pathology
Generalized anxiety
Tx
Treatment:
Psychotherapy/CBT
Rx:
1-SSRI ( start lower doses) or -SNRI
2-buspirone
Benzodiazepine for panic attacks
Beta-blockers, TCA
Generalized Anxiety Disorder
Diagnostic Criteria DSM-V
Patient presents with insomnia, fatigue and “constant worry” about multiple things daily for > 6 months. Which of the following is best therapy for patient?
Alprazolam (Xanax)
Buspirone (Buspar)
Fluoxetine (Prozac)
Hydroxyzine (Vistaril)
C- fluoxetine. Diagnosis is Generalized Anxiety disorder. Drug of choice is SSRI + CBT
If needed add on therapy SNRI or Buspirone ( 2nd line)
Prn symptoms Vistaril, xanax
Separation Anxiety Disorder
General and Tx
uncontrollable apprehension regarding separation or loss of figure(s)
Excessive worry about something happening to figure
Symptoms > 6 months in adults; > 4 weeks in children
“normal” in children < 4 yoa
Often leads to panic disorder in adulthood
Treatment
CBT
Play-therapy (for patient and family)
Separation Anxiety
Diagnostic Criteria DSM V
Separation Anxiety Examples
Children refusing to go to school, sleep overs, camp, temper tantrums when figure leaves
“Nightmare in the closet”
Most prevalent anxiety disorder in children < 12
Can be triggered by a stressor- ie moving, changing schools, divorce, death in the family
Can present in adults too!!!
Tx: CBT
? Do you feel anxious, fearful, or upset thinking about separation, or being away from….
Adults can have separation anxiety as well- usually involve separation from child, or someone else in a relationship with
Separation Anxiety Patient Education
What is treatment of choice for separation anxiety disorder?
A- Benzodiazepine prn
B-Cognitive Behavioral Therapy
C- EMDR
D-Flooding and Graduated Exposure therapy
E-SSRI
B- CBT
Panic Disorder
general
Extreme worry/anxiety peaks within 10 minutes and declines within 30 minutes
Insidious vs identifiable trigger
Associated debilitating symptoms
3 x more common in women vs men
Onset usually in 20’s but may occur in childhood
High recurrence if medications are discontinued
Workup: r/o other pathology
Workup: depends on symptoms, must rule out underlying pathology- especially life-threatening; associated disorders
ECG, enzymes, TSH, holter, asthma, COPD
Presentation
Men greater than women, age 20’s
Panic Disorder
Tx
Acute phase: benzodiazepine ( caution)
CBT
Chronic phase: SSRI, TCA
* may see beta blockers ( propranolol)
* may see antihistamine ( hydroxyzine)
Treatment
Acute: benzo
Chronic:1- SSRI, 2-TCA
Cognitive behavioral therapy is the mainstay of therapy-( Flooding and Graduated Exposure) improvement from chronic Rx therapy likely due to improved underlying GAD
Panic disorder
Diagnostic criteria
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
Note:The abrupt surge can occur from a calm state or an anxious state.
Palpitations, pounding heart, or accelerated heart rate.
Sweating.
Trembling or shaking.
Sensations of shortness of breath or smothering.
Feelings of choking.
Chest pain or discomfort.
Nausea or abdominal distress.
Feeling dizzy, unsteady, light-headed, or faint.
Chills or heat sensations.
Paresthesia (numbness or tingling sensations).
Derealization (feelings of unreality) or depersonalization (being detached from oneself).
Fear of losing control or “going crazy.”
Fear of dying.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).
Panic Attack Unprovoked, acute
S: shortness of breath
T: trembling
U: unsteady
D: depersonalization
E: excessive heart rate
N: numbness
T: tingling
S: sweating
P: palpitation
A: abdominal pain
N: nausea
I: inert fear/impending doom
C: chest pain
Phobias
general and tx
A situational fear (exaggerated vs irrational)
Lasts > 6 months
Can be specific vs situational
Usually learned/rooted in experience
Cannot control response to trigger
Often occur in childhood and solidify in adulthood
Often have substance abuse, chronic anxiety, and personality disorder
Treatment
CBT with exposure therapy
Specific Phobia Diagnostic Criteria
Social Phobias
general and tx
Less common; > 6 months
Onset in adulthood
Public speaking, public urination/defecation; public eating
Tx: exposure therapy
Flooding: works quickly but not as effective
Desensitization: more effective over time
Rx: non-selective BB
Specific phobias
general and tx
More common; < 6 months
Onset < 12 yoa
Clowns, crowds, heights, spiders
Tx: exposure therapy
Flooding: works quickly but not as effective
Desensitization: more effective over time
Rx: use benzodiazepine to stabilize during acute
Social Anxiety Disorder
general and tx
Most common type of phobia
Disabling, > 6 months intense fear of social or performance situation based on perceived scrutiny of others
Causes anxiety and can lead to panic attacks
Often person is fearful and avoidant of these situations
Subtype is performance anxiety
Treatment:
CBT, desensitization
1- SSRI, 2- SNRI
Prn benzo
Beta blockers
Obsessive Compulsive Disorder
General
Repetitive/ritualistic behaviors to relieve anxiety
Has obsession (intrusive thought) that creates anxiety- has compulsions ( recurrent pattern of behavior) to relieve anxiety
Patients are looking externally to feel control over an internal process
Is distressing to patient, impairs function
2/3 diagnosed before 25 yoa
It is important to identify the obsession and the compulsion: what is the thought? What does this make you feel like you have to do?
75% of patients have another anxiety disorder
? Hypothesis that there is an association with OCD and early childhood infection with group A streptococcal infection. Group A strep infection leads to an autoimmune response which damages the basal ganglia
Obsessive-Compulsive Disorder
Diagnostic Criteria (300.3)
Conditions that may mimic OCD
ADHD
Difficulty with focus and inability to complete tasks- determine if mental rituals or obsessive thoughts interfere with focus and attention
Anxiety Disorder
Worry about many things frequently, can mimic obsessive thinking but does not have irrational quality of OCD or the ritual
Autism spectrum disorders
Often engage in repetitive behaviors but do not perceive them as odd; OCD rituals are aware they are unreasonable and excessive; OCD can demonstrate social isolation but communication skills are preserved
Obsessive Compulsive Disorder
Types
Obsessive Compulsive Disorder
Tx
Tx:
cognitive behavioral therapy
exposure response therapy
relaxation therapy
transcranial magnetic stimulation
Rx:
1-SSRI ( usually higher doses/long duration).
2- TCA (Clomipramine/more side effects)
3- anti-psychotics
- do not use benzodiazepine unless have panic attacks; the use of benzo will become part of the ritual
Hoarding Disorder
general and tx
Fear of throwing things away
Becomes unsafe living environment
Often goes unnoticed
Often have OCD, ADHD, and/or Depression
Tends to escalate with age
Tx: CBT
Hoarding Disorder
Criteria
Body Dysmorphic Disorder
diagnostic criteria
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occupational or other areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
Body Dysmorphic Disorder
general and tx
Female > male
Preoccupation with part of body ( usually skin, hair, nose, breast) appearance
Constant checking appearance
Unnecessary surgeries, procedures
Tx: CBT/ SSRI ( higher doses, usually takes 10-12 weeks)
Muscle dyphoria
General and tx
Male > female
Obsession with increasing muscle mass
Anabolic steroids ( copper disorder, hair growth, testicular atrophy)
Can be challenging to distinguish in athletes; desire look better not perform better
Leads to rhabdomyolysis
Tx: CBT/SSRI ( higher doses, usually takes 10-12 weeks)
